For most of my career, the driving force behind the diagnosis and treatment of breast cancer has been the belief we needed to move as quickly as possible to eradicate the cancer before it had the chance to spread. Even though recent studies have shown that breast cancer cells can begin circulating in the bloodstream much earlier than we suspected, this approach has persisted. Then came COVID.
As hospitals filled with COVID patients, limiting their capacity to treat other patients and posing a risk to newly diagnosed cancer patients, breast oncologists faced a situation that pushed that them to re-think how they delivered treatment. An article in the New England Journal of Medicine outlined an example of how this shift has occurred at Massachusetts General Hospital in Boston.
The authors described the case of a 62-year-old woman who was diagnosed after a core biopsy with a 1.6 cm, grade 2 breast tumor that was ER-positive, PR-negative, and HER2-negative. Normally, the treatment for this type of tumor is fairly straight forward: a lumpectomy or mastectomy followed by hormonal therapy (most likely an aromatase inhibitor) for five years or more. But COVID times are not normal times. So, what did the woman’s oncologists do? Instead of starting with surgery, they started with hormonal therapy.
When drug therapy is given before surgery, it is called neoadjuvant therapy. It has two advantages. First, it allows the treatment team to see if the cancer will respond to the therapy, be it hormone therapy, chemotherapy, or targeted therapy. Watching a tumor shrink away in response to a drug therapy is typically very satisfying to the doctors and the patient. It also often means that less tissue needs to be removed from the breast. The other benefit is that any potential cells that have already left the tumor and begun to circulate through the body will be treated by the drug therapy.
This approach is probably not typically used for hormone-sensitive tumors because it takes much longer for a tumor to respond to and shrink from a hormonal therapy than it does from chemotherapy or a targeted therapy. One study found that 70% of patients who received hormone therapy (in this case an aromatase inhibitor) had a partial or complete response after 3 or more months of treatment. Neoadjuvant therapy is, however, more commonly used to treat patients with triple-negative breast cancer or large breast tumors.
The ways in which the pandemic has required people to adapt to working from home and to online schooling is well known. It’s great that oncologists are letting the world know how they are adapting their treatment approaches to breast cancer in ways that do not sacrifice adequate treatment while keeping everyone as safe as possible.